Casualty Decontamination and Hospital Decontamination Station

Introduction

Disasters involving chemical release are of concern in our modern industrialised

world because of the propensity for such incidents to cause injury and death in large
numbers. One example of a hazardous material incident was the Bhopal incident in India in
which methyl isocyanate was accidentally released into the environment. In more recent
times, it appears that chemical agents that were once intended for use on the battlefields
have now been applied to civilian populations by small groups of deviants and terrorists to
create public havoc and mayhem. In the wake of the 911 incident, it is even more important
for public hospitals to be prepared to deal with such situations.

The Need for Decontamination

A significant difference between hazardous materials incidents when compared with

conventional disasters is the presence of chemical contamination of the environment and
casualties from the incident. The hazardous environment will predispose casualties to
chemical toxicity as well as pose added risk to the rescuers and healthcare personnel
dealing with contaminated casualties. In the sarin incident in Tokyo in 1995, it was noted that
approximately 10% of rescue workers (EMTs or Emergency Medical Technicians) and 23%
of hospital staff dealing with chemical contaminated casualties suffered from symptoms due
to secondary exposure to chemicals off gassing from the casualties clothing. Similar
problems of secondary exposure among rescue personnel and hospital staff were noted in a
similar attack involving sarin in Matsumoto, Japan in 1994. It is noteworthy that no field or
hospital decontamination of casualties was done in both of these incidents. Our local
experience in treating casualties of accidental teargas exposure has revealed the potential
risk of secondary exposure to hazardous materials by healthcare workers and has
demonstrated the benefits of timely decontamination. Hence, in chemical disasters, it is of
paramount importance to decontaminate casualties especially those who are contaminated
by chemical which pose a liquid threat. This should be done thoroughly to reduce the toxic
effects on the casualty as well as to decrease the risk of secondary contamination. The latter
is important so as to reduce the escalation of the event due to spread of contamination and
also to reduce the loss of limited civil defence and healthcare resources at a time of
increased demand in a disaster situation.

Hospital Decontamination Station Layout

The HDS is organised into 4 main sections, namely the dirty area or Hot Zone, decon
area or Warm Zone, buffer zone and clean area or Cold Zone. The dirty area is the first
point of contact for contaminated casualties with the hospital. In this area, HDS staff don
semipermeable protective suits and air purifying respirators providing Level C protection,
while they assess, triage and treat chemical contaminated casualties that are brought in from
the scene of a Hazmat incident. In the decon area, staff don impermeable splash suits and
air purifying respirators, also providing Level C protection and perform systematic
decontamination as described in the subsequent section. At the buffer zone,
decontaminated casualties from the decon area are dried before chemical agent monitors
(CAMs) are applied systematically to screen for residual chemical agents, including nerve
agents and blister agents. HDS staff in this area don the same suits as their colleagues in
the decon area. Casualties with residual contamination identified by the CAMs will be
redirected through the decontamination cycle again, focussing on hot spots or areas of
residual contamination on the body identified by the CAM. Clean casualties with no residual
contamination will be allowed to proceed to the clean area where conventional triage and
treatment will be continued. HDS staff working in this area follow universal precautions -
wearing surgical masks, gowns and gloves while managing casualties (Level D protection).
HDS staff working in different sections are not allowed to cross to other areas in order to
reduce cross contamination. Each designated staff in a particular area has a specific role,
which will be assigned to them upon reporting following activation. All HDS staff are cross-
trained, tested and certified in all the roles so that they are able to take up responsibilities in
any area of the HDS.

Decontamination: Step by Step Procedure

Decontamination is the process of removing contaminants from the skin and hair of
individuals exposed to hazardous materials. There are many methods that can be used in
this regard but the method adopted currently involves the use of specially built shower
facilities for washing down contaminated casualties. The following phases describe the
decontamination process:

1. Arrival and reception of contaminated chemical casualties.

2. Initial triage and treatment by protected triage teams wearing personal protective
equipment (PPE).

3. Entry into the decontamination showers

4. Disrobing of casualties and collection of property in property bags

5. Showering of casualties in a supervised environment

6. Screening of casualties for any further contamination

7. Re-clothing and transfer of casualty to clean area

8. Re-triage of casualty at the mass casualty triage point outside the Emergency
Department

9. Recovery phase

Arrival and Reception of Contaminated Chemical Casualties

This phase involves the reception and co-ordinated transfer of non-ambulant contaminated
casualties from ambulance trolley to specially designed decontamination stretchers and then
to the chemical casualty triage point for further evaluation. All staff involved in management
of the casualties are required to be in Level C protection i.e. wearing respiratory protection
with carbon impregnated canisters and full dermal protective suits. Ambulant contaminated
casualties will be guided to the chemical casualty triage point.

Initial Triage and Treatment by Triage Teams Wearing PPE

At the chemical casualty triage point, specially trained triage team members wearing PPE
will triage and tag chemical casualties according to severity of injury. Management of the
airway, breathing and circulation or ABCs will occur simultaneously. The triage team leader
will initiate the administration of specific injectable antidotes for nerve agent intoxication here
upon identification of nerve agent toxidrome. Although the protective garments impede
specific toxidrome recognition and subsequent treatment of the casualty, it is important that
an attempt is made to look for specific toxidromes such as the nerve agent toxidrome. This
should be done taking into consideration circumstantial evidence provided by security and
related agencies as well as correlation with the clinical picture. This is important so that the
casualty may be given the injectable nerve agent antidotes available which will buy time for a
thorough decontamination to be done before further assessment and treatment by non-
protected medical personnel is commenced.

Entry into the Decontamination Showers

Non-ambulatory and ambulatory casualties will be directed to the respective

decontamination showers for ambulant and non-ambulatory casualties after the triaging
process.

Disrobing of Casualties and Collection of Property in Property Bags

During this phase, casualties will be systematically disrobed and their valuables collected
and tagged for subsequent identification. Ambulatory casualties will be supervised during
disrobing while non-ambulatory casualties will be disrobed by crew members. This important
step is expected to remove 80 to 90% of contamination, depending on the body surface area
covered by clothing items on the particular casualty. Due care is taken by following special
techniques in this process so as to reduce the chances of contamination of the skin from the
contaminated outer garments. In addition, special effort will be made so as not to destroy
crucial evidence during the disrobing process.

Showering of Casualties in a Supervised Environment

During this phase, meticulous showering is performed,starting from contaminated wounds to

areas of obvious contamination and finally, a head-to-toe scrub followed by shower.
Ambulant casualties are supervised closely while showering in order not to omit important
details. The whole process takes 10 minutes and basic life support measures, such as
rescue breathing, are performed continuously without interruption throughout the whole
process. Although a variety of decontamination solutions are available, the showering
process in the HDS involves the use of soap and water for logistical reasons. Effluents from
the decontamination process are collected into special bladders for subsequent testing and
treatment before disposal into the sewerage system.

Screening of Casualties for Residual Contamination

A systematic chemical agent screen using military CAMs is done for all casualties following
decontamination. Any casualties with residual contamination detected will be sent back
through the decontamination chain for re-decontamination.

Re-Clothing and Transfer of Casualties to Clean Area

Patients cleared of chemical contamination are carefully transferred to a clean area before
being sent to the mass casualty triage point for further assessment and management.

Re-Assessment of Casualties at the Mass Casualty Triage Point Outside the

Emergency Department

At the mass casualty triage point, reassessment and re-triaging will be carried out and
appropriate further treatment will be continued in the Emergency Department.

Recovery Phase

When the last casualty has been decontaminated and the incident has been declared over,
the recovery phase will start. During this phase, the HDS crew will first proceed to
decontaminate the station and clean up the facility before proceeding to thorough personal
decontamination. The HDS will be reinstalled and logistics replenished so that the HDS will
be ready for the next activation. A debrief session for the crew will be held and lessons learnt
will be noted and procedures updated in order to improve future operations.

The persons behind the masks

The HDS crew are the pillars for the successful operations of the HDS. These staff
may be recruited from various departments within the hospital and include nurses, doctors,
hospital maintenance crew, physiotherapist, healthcare attendants, and administrators. All
selected staff are physically fit and are assessed on their endurance and ability to withstand
rigorous training in less than ideal conditions. They also have to undergo specialised training
which includes the use of PPE such as gas masks and protective suits, operation of
chemical agent detectors, carrying out of decontamination procedures on ambulant and non-
ambulant casualties. They are also specially trained in chemical agent recognition, triage
and specific antidote administration.

This handout is adapted from Decontamination Rationale and Step-By-Step Procedure published in
SGH Proceedings VOL 12, NO 4 ,2003